Table of Content

Archive

Winter 2019, Vol. 27 No. 4

Hong Kong J. Dermatol. Venereol. (2019) 27, 192-195


Reports on Scientific Meetings

Hong Kong Dermatology Symposium 2019

Reported by KF Cheng 鄭劍峰, HL Lo 盧曉麗, MF Yeung 楊明晃

Date:   27 October 2019
Venue:   Prince of Wales Hospital
Organiser:   Hong Kong Dermatology Foundation

Critical care dermatology

Speaker: KI Law
United Christian Hospital, Hong Kong

A total of 2,245 dermatological admissions were identified among 476,224 admissions to 178 ICUs in England over the time period December 1995 to September 2006 according a study in United Kingdom (Crit Care 2008; 12 (Suppl 1): S1). Conditions included infectious conditions (e.g. cutaneous cellulitis, necrotising fasciitis), dermatological malignancies, and acute skin failure (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome and autoimmune blistering diseases). It accounted for 0.47% of all ICU admissions, or approximately 2.1 dermatological admissions per ICU per year.

Dermatology in critical care included a few aspects: (a) multisystem disorders with cutaneous signs; (b) skin conditions developing as complications of intensive care; (c) primary dermatological conditions. The speaker illustrated some examples with clinical photo.

Vascular phenomena are one of examples of dermatological manifestation in critical care. Septic embolism causing gangrene of fingers, Janeway lesions secondary to underlying infective endocarditis. Diffuse purplish discolouration of extremities after septicaemic shock might require orthopaedic surgeon to intervene. An intubated patient due to upper airway obstruction was found to be a hypertensive patient taking angiotensin-converting enzyme (ACE) inhibitor. A young gentleman presented with fever and recent picnicking was noted to have eschar formation caused by rickettsial infection.

Pressure ulcers often occur as a result of immobility, lack of sensory perception, poor nutrition and hydration, medical condition affecting blood flow. Common sites are back and side of the head, shoulder blades, hips, lower back or sacrum, heels and ankle etc. Sometimes pressure ulcers could occur around the face and nostril due to chronic use of assisted ventilatory devices.

Patients with toxic epidermal necrolysis due to severe adverse drug reactions could result in dehydration, sepsis, pneumonia and multi-organ failure. Necrotising fasciitis is another important disease with rapid spreading of necrosis of body parts. It presented as red or purplish skin with severe pain, fever and vomiting. It is treated with surgery of the devitalised infected tissue together with parenteral antibiotics.

Learning points:
Numerous cutaneous problems occurred in intensive care setting including primary dermatological conditions, multisystem disorders with cutaneous manifestation and complications from intensive care.

Metabolic syndrome in Hong Kong psoriasis patients

Speaker: CW Chow
Social Hygiene Service, Hong Kong

Psoriasis is a common, chronic, immune-mediated inflammatory skin disease. Prevalence of metabolic syndrome is increasing globally. The speaker performed a study to investigate the prevalence of metabolic syndrome among Chinese psoriasis patients attending specialist dermatology outpatient clinics of Social Hygiene Service and to identify any association between demographic and clinical parameters and metabolic syndrome. It was a cross-sectional study of 419 psoriasis patients attending specialist dermatology outpatient clinics between November 2017 and May 2018. The study demonstrated the prevalence of metabolic syndrome was 39.9%. In the final multivariate regression model, the following were found to have association with metabolic syndrome: (1) patients who were married (OR 2.604, 95% CI 1.274-5.320), (2) older at the age of onset of psoriasis (OR 1.049, 95% CI 1.029-1.07), (3) longer duration of psoriasis (OR 1.038, 95% CI 1.011-1.067) and (4) elevated C-reactive protein (OR 2.327, 95% CI 1.26-4.295).

Metabolic syndrome is a cluster of disorders including central obesity, hypertension, impaired glucose tolerance and dyslipidaemia. Metabolic syndrome is a predictor of cardiovascular disease and diabetes. Clinical implication includes raising the awareness of physicians in Hong Kong taking care of psoriasis patients to understand the association between psoriasis and metabolic syndrome and early identification of metabolic syndrome among psoriasis patients. Appropriate management, multidisciplinary approach with primary family physicians or endocrinologists will lower the cardiovascular risk of psoriasis patients having metabolic syndrome.

Learning points:
Early identification and targeted management of metabolic syndrome among psoriasis patients could lower the cardiovascular risks and complications of these patients.

Congenital sexual transmitted infections: How to prevent them?

Speaker: WYK Lam
Private Dermatologist, Hong Kong

Transplacental, intrapartum and postpartum exposure are the routes of transmission of congenital sexually transmitted diseases. Congenital infections caused by human immunodeficiency virus, syphilis, herpes simplex virus, human papillomavirus, gonorrhoea and chlamydia were discussed.

Congenital syphilis is nowadays rare because of routine antenatal screening and easily available penicillin treatment. Vertical transmission happens mostly after 16 weeks of gestation. Therefore, treatment before 16 weeks of gestation should prevent most of the foetal infection. Congenital syphilis could at times lead to miscarriage, stillbirth and neonatal death. For survivors, different manifestations exist e.g. papulosquamous plaques, pemphigus syphiliticus, Hutchinson's triad and depends on the stage of congenital syphilis.

Anogenital warts in pregnant women is not necessarily an indication for Cesarean section. Caesarean section is indicated if there is pelvic outlet obstruction or when vaginal delivery will likely result in excessive bleeding. Cryotherapy, laser or surgical removal are treatment options for warts in pregnancy.

Congenitial HIV infection remains uncommon due to measures such as antenatal screening, antiretroviral treatment and elective Caesarean section. Infants born to women with HIV infection should receive postpartum antiretroviral drugs as close to the time of birth as possible.

Chlamydial infections in neonate may lead to severe manifestations such as ophthalmia neonatorum and pneumonia. Therefore, initial antenatal screening and rescreening in the third trimester for women at increased risk is essential. Test of cure after 3-4 weeks and test of reinfection at three months are also beneficial.

Neisseria gonorrheae can lead to conjunctivitis, rhinitis, arthritis, meningitis and even sepsis in neonate. Antenatal screening with prompt treatment and test of cure is essential to prevent the congenital infection.

Neonatal Herpes manifestations range from disease localised to skin, eye and mouth to CNS disease and disseminated infection. Risk of transmission to the neonate is highest in mother with primary genital herpes near the time of delivery. Caesarean section and administration of acyclovir to neonates could be considered.

Learning points:
It is imperative to educate pregnant ladies on the importance of antenatal screening. Antenatal screening together with appropriate treatment and delivery plan, the risk of neonates acquiring congenital sexually transmitted diseases can be greatly reduced.

Common paediatric hair and nail diseases

Speaker: FFC Ip
Social Hygiene Service, Hong Kong

Disorders associated with hair and nail are largely benign and mild in the paediatric population. The main concern is more often related to the cosmetic and psychosocial aspects. Hair and nail disorders may be isolated or global, which can affect more than one appendage. Occasionally, the abnormalities may be a clue to an underlying systemic condition e.g. connective tissue disease.

Alopecia is one of the common presentations of hair disorders in the paediatric population. Hypotrichosis and atrichia can be congenital or acquired. Their distribution can be diffuse or localised. Rarely, they may present as part of the underlying abnormalities such as severe ichthyosis and ectodermal dysplasias. Acquired hair loss such as alopecia areata, trichotillomania and tinea capitis are more frequently seen than the congenital conditions.

Nail disorders can present as alterations in nail plate, size and shape. Infections and disease in nail bed can be encountered. Nail changes can sometimes provide us clue to aid the diagnosis of underlying disease such as psoriasis.

Learning points:
Despite hair and nail disorders in paediatric population are largely benign although they may cause concern especially in the parents. Moreover, hair and nails disorders can occasionally be a clue to an underlying systemic condition.

Cutaneous complications of body art: an overview

Speaker: NM Luk
Hong Kong Dermatology Foundation, Hong Kong

Common complications of body art (tattooing and body piercing) include cutaneous infections (bacteria, viral, fungal) via needle trauma with unsterile equipment, and allergic reactions (type I or IV reaction) which usually cannot be detected by patch test. Patients who develop allergic reactions with tattoos are not be suitable for tattoo laser removal. Other complications include Koebner phenomenon, hyperpigmentation or hypopigmentation, parasitic infestation and keloid formation. Serious complications such as septicaemia and generalised eczematous reaction have also been reported. In addition, psychological complications; interference with medical investigations; potential carcinogenic risks are important issues. There are also complications from body art removal e.g. burn injury, bleeding, dyspigmentation, scarring, wound infections and also carcinogenic potential of degraded dye molecules.

Learning points:
Body arts have gained popularity and has been accompanied by an increase in its related complications e.g. infection and allergic reactions. Tattoo inks are poorly regulated and may contain harmful impurities. In addition, photodegradation (sun or laser) of tattoo dyes may release allergens / carcinogens and tattoo removal may not be easy and is not without risk.

Application of genetic and genomic tests for genodermatoses in Hong Kong

Speaker: HM Luk
Clinical Genetic Service, Department of Health, Hong Kong

The genodermatoses are a large group of inherited disorders with skin manifestations of which many are rare. However, the recognition of genodermatoses is important, not only for the medical management but also for the genetic counselling and family cascade screening.

Clinical genetic services in DH includes genetic counselling division, genetic screening division, cytogenetic & molecular laboratory and genetic health promotion programme. Genetic counselling includes family history evaluation, education, risk assessment, management recommendations, genetic testing and interpretation of results. With the advance of DNA sequencing techniques, the cost and time for genetic testing has much reduced. Genetic testing is guided by the cutaneous and systemic manifestations and the background medical and family history of the patient. A negative family history does not rule out a genetic skin disorder.

Clinical features which may suggest genodermatoses include erythroderma, collodion baby, or generalised blistering at birth; therapy-resistant eczema with recurrent infections, palmoplantar keratoderma, generalised scaling, poikiloderma or photosensitivity during childhood. Other features include multiple adnexal tumours during adolescence; cutaneous lesions in a linear or segmental distribution, multiple hypo- and hypermelanotic macules, or association with various extracutaneous manifestations especially when involving the CNS, skeleton, teeth, eyes and ears in any age groups.

Learning points:
Diagnosing genodermatoses is important for optimal management by providing information on the natural history or prognosis of the disease, reproductive risk and family planning advice, and assess for targeted therapies. In the future, earlier a more in-depth genomic investigation may be possible if a joint liaison dermatologist clinical geneticist clinic is available.